Section 1: Multidisciplinary Team

Guideline I
There is a coordinated multidisciplinary team approach to planning, implementing, and evaluating the care of cancer patients—inpatient and outpatient—and their families.

Rationale
An organized, consistent multidisciplinary team approach to the care of cancer patients and their families is necessary to ensure that needs are identified, interventions are planned, treatments are coordinated, and care is monitored and evaluated.

Characteristics

Multidisciplinary services include, but are not necessarily limited to:

Physician services

Attending physician and/or oncology specialists such as medical oncologists, radiation oncologists, surgical oncologists, and other physicians
from medical specialties involved in the care of cancer patients and their families

Multidisciplinary team members have access to in-service and continuing education programs with appropriate credit (CME I is preferred) for program
attendance. (See Chapter 7, Professional Education and Staff Support.)

REFERENCES

Please note: While every attempt has been made to ensure the accuracy of the publications, addresses, phone numbers, and websites, ACCC cannot ensure that this information has not changed. Web addresses, in particular, change frequently. If you find that a web address has changed, try to locate the publication name through an online search engine.

Section 2: Oncology Unit

Guideline I
An inpatient oncology unit, or functional equivalent general medical/surgical unit, is designed for the care of patients with cancer and their families.

Rationale
The inpatient oncology unit is a dedicated area developed to adequately and competently meet the complex and unique needs of cancer patients in a safe setting.

Characteristics

Written policies and procedures document the philosophy, mission, and goals for patient care on the inpatient unit. Admission criteria, discharge criteria, and patient care policies and procedures are also documented.

Space is provided for cancer patients needing isolation for infection control or for radiation implants, as well as for
comfort and privacy for family and friends through the terminal stages of disease.

Multidisciplinary team services are provided to the patient and family, including self-care proficiency, discharge planning and
referral to home health, hospice, homemaker services, psychosocial services, and rehabilitation services.

Referral mechanisms for services not readily available are documented.

Comprehensive performance improvement plans are implemented and results reported to staff, administration, and the Cancer Committee on a monthly, quarterly, and yearly basis.

Structure and function of the unit are centered around creating an ambiance of patient-centered care and include liberal visiting
hours, family room, access to food pantry, and educational and support activities.

Access to medical records to both read and contribute by all members of the multidisciplinary team.

Accreditation by the Joint Commission on Accreditation of Healthcare Organizations (JCAHO), American College of Surgeons’ Commission on Cancer, and other accreditation as required for licensure.

Patient education is provided and reinforced to ensure the patient and family understand therapy options, participate in therapy selection and plan, and are observed to demonstrate understanding and sufficiency in self administration of therapy, self monitoring, and adherence to the therapy plan.

Section 3: Ambulatory Oncology Services

Guideline I
An outpatient facility or office is available and dedicated to outpatient cancer care.

Rationale
A dedicated site for ambulatory cancer care allows optimal coordination of care, consolidation of qualified staff, and easy access to efficient services through focused facility design and operations.

Characteristics

An ambulatory facility includes, but is not limited to:

Qualified and experienced oncology staff, including registered nurses and other licensed professionals experienced in oncology, as required

Adequate facilities for all or some of the following:

Drug storage, preparation, dispensing, and disposal of cancer therapeutic agents and other pharmaceuticals following all regulatory
agency guidelines (Hospital-based ambulatory services must include a licensed pharmacy.)

American College of Radiology (ACR) or American College of Radiation Oncology (ACRO) accreditation recommended (In lieu of accreditation, program should adhere to the standards for accreditation of ACR or ACRO. In addition, accreditation by the JCAHO and the American College of Surgeons’ Commission on Cancer, as appropriate, is recommended.)

Please note: While every attempt has been made to ensure the accuracy of the publications, addresses, phone numbers, and websites, ACCC cannot ensure that this information has not changed. Web addresses, in particular, change frequently. If you find that a web address has changed, try to locate the publication name through an online search engine.

American College of Radiology. Compliance Program Guidelines for Radiologists and Radiation http://www.acr.org.
Phone: 703.648.8900.

Certification in oncology nursing by the Oncology Nursing Certification Corporation (ONCC) is recommended.

Management experience is recommended.

Oncology nursing services provide adequate staffing to meet the needs of patients and their families:

The facility determines and justifies nurse staffing according to a patient care acuity system.

Staffing levels and services to fulfill standards are reviewed annually.

An appropriate clinical nursing expert is a member of oncology nursing services or is available on a consultant basis.

A master’s prepared oncology clinical nurse specialist or nurse practitioner is available to medical staff, patients, and families.

The nursing expert is available for team consultation, education, research activities, and case management.

A plan is in place regarding ongoing staff development, including participation in multidisciplinary team conferences,
regularly scheduled in-service and continuing education programs, national and regional professional organizations, and community-sponsored programs specific
to oncology nursing. Oncology nursing certification is encouraged and recognized.

Oncology nursing practice policies and procedures are written and approved by nursing and include, but are not limited to:

Administration, monitoring, and safe disposal of cytotoxic and biological agents

Written patient care guidelines, which are culturally sensitive, developed, reviewed, and revised annually by practicing oncology nurses with input from the multidisciplinary oncology team

Oncology Nursing Society standards and guidelines for all aspects of patient care, professional practice, research, education, and administrative components should be referenced when developing same within individual programs.

The oncology nurse provides patient and family education relative to all aspects of oncology care including discharge tracking.

REFERENCES

Please note: While every attempt has been made to ensure the accuracy of the publications, addresses, phone numbers, and websites, ACCC cannot ensure that this information has not changed. Web
addresses, in particular, change frequently. If you find that a web address has changed, try to locate the publication name through an online search engine.

The Oncology Nursing Society position papers. Available at:http://www.ons.org/publications/positions.
Including position papers on cancer pain management, oncology services in the ambulatory practice setting, end-of-life care, and mammography screening.
Phone: 866.257.4667.

Section 5: Pharmacy Services

Guideline I
Pharmacy services pertain to those staff who are responsible for any aspect of drug therapy, from procurement to final disposition and documentation. A pharmacist should be available to the cancer program, either as an employee, or as a consultant to train, certify, or advise the staff responsible for Pharmacy Services.

Rationale
Pharmacy Service standards and guidelines are addressed by several regulatory agencies and professional organizations. Standards and guidelines sometimes
apply to a specific setting (e.g., JCAHO for hospitals), but the principles pertaining to quality, safety, and effectiveness of cancer care should be considered in all settings.

Guideline II
Pharmacy Services will be responsible for the procurement, storage, preparation, distribution, and disposal of commercial and investigational cancer chemotherapy and other medications in a safe and accurate manner.

Rationale
The Pharmacy Service institutes safeguards that will protect patient safety, ensure accuracy and clinical appropriateness, and provide safe handling to
minimize environmental and personnel exposure to cancer medications.

Characteristics

Pharmacy Services obtain commercial and investigational cancer chemotherapy. All staff involved with receiving cancer therapeutic agents are trained for the appropriate procedure in the event of breakage, leakage, or other product damage.

All commercial and investigational drugs and pharmaceuticals are stored and labeled to conform with all regulations for security, storage conditions, and safety (e.g., cancer therapeutic drugs will be labeled “chemotherapy” and separated from other inventory; investigational drugs will be stored separately in a locked area).

Documentation of receipt and distribution of investigational agents is maintained on a perpetual inventory log.

Only chemotherapy-trained personnel will prepare and dispense cancer chemotherapy. Chemotherapy training, competency assessment, and
re-certification are provided to personnel on annual basis by review of policies and procedures and updated to conform to new literature and standards for
preparation, aseptic technique, and safe handling. Competency is based on observation of personnel work practices and their understanding of policy.

Preparation policies and procedures include, but are not limited to:

An appropriate environment, employee garb, work process, and environmental testing that conform to current USP Chapter 797 regulations

Established and available standards for dilution of solutions, concentrations, compatibility, and stability, along with current reference information

Appropriate labels indicating a “chemotherapy” and/or “investigational” medication, all contents, final volume, and other ancillary information as required

Disposal procedures for syringes, needles, and drug waste that conform to OSHA, EPA and other regulatory agencies

Spill procedures and a spill kit at the preparation site

Redundant checks in place to ensure the accuracy of the final product, and the appropriateness of the therapy and dose, including the scheduling of the current therapy (e.g., this is not the second day of a single day therapy)

For infusion bags, tubing is attached and purged prior to the addition of cancer chemotherapy.

Extravasation guidelines are available which include, but are not limited to:

A list of cytotoxic vesicants/irritants (medications known to cause tissue damage upon extravasation)

A list of antidote and other treatments for each cytotoxic vesicant (e.g., heat/cold therapy)

Extravasation kits available at the administration site

Investigational medications will be dispensed following federal, IRB, and study sponsor requirements, including

All inventory tracking requirements

Verification of informed consent prior to preparation of the drug

Investigational protocol, which is available to all staff involved with preparing, administering, or monitoring the drugs and agents that are involved.

Guideline III
Clinical Pharmacy services will be established to ensure the appropriateness and safety of therapy.

Rationale
A multidisciplinary approach should be used in assessing the patient, obtaining medication history, and developing a therapy plan based on the patient’s current condition, physiological changes, and reaction to previous therapy. Current medication plans will be reconciled with other providers to ensure coordination and optimizing of the patient’s total care.

Characteristics

All cancer-related medications should be ordered on hospital-approved chemotherapy treatment order form(s), or equivalent electronic record, that is signed by an authorized physician prior to preparation or treatment.

Pharmacists, working with the multidisciplinary team should develop pre-printed or computer-embedded order sets (protocols) that include all medications, required monitoring, other orders that are required, and conditions for administration (e.g., lab values).

Individual orders should be linked in a time sequence beginning with pre-medication and hydration therapy. Protocols that extend over several days should clearly state which day the therapy is (e.g., Day 2 of 5).

Orders should include the course of therapy (e.g., Cycle 2 of 6).

Orders should indicate the time interval between cycles.

Orders should include the protocol name, course of therapy, diagnosis, dosing weight, and references for the therapy.

Evaluating other medications and therapy the patient might be taking for appropriateness with respect to the oncology-related treatment plan, including taking or reviewing a comprehensive medication history.

All patients will be monitored for the overall use of cancer chemotherapy and other agents in the treatment of cancer patients, adverse effects (ADRs, medication errors), and patient outcomes in collaboration with the medical and nursing staff.

Current clinical information should be available for commercial and investigational cancer chemotherapy pertaining to safety, dosing, therapeutic uses, and toxicity.

Pharmacy Services will establish criteria to ensure that JCAHO and other standards that promote medication reconciliation are met by providing the following. This includes all prescription and alternative medication, vitamin, nutritional, and herbal products.

Comprehensive review of medication history

Assessing patients’ understanding of why they are taking their therapy, and what conditions they are being treated

Reconciling current medication plan with therapy that will be continued

Educating patients and ensuring they understand what medication will be continued, what will be discontinued, and what the new plan includes, and why they are receiving the therapy

Contacting other providers who provide care before, after, or concurrently to ensure they also reconcile the patients’ total therapy needs

Ensuring thorough documentation in the patient medical record.

Guideline IV
Appropriate drug-related education will be provided to patients and staff.

Rationale
It is important to incorporate new scientific discoveries and standards into practice as soon as possible, by educating patients and members of the multidisciplinary team.
Training new staff and retraining established staff on a regular basis are important. Specific areas of focus include pharmacology, pharmacokinetics,
pharmacodynamics, drug compatibility, drug administration, drug therapy interactions in patients taking multiple therapeutic agents, adverse effects of
medication, medication outcomes, and taking comprehensive medication histories.

Characteristics

Staff should follow JCAHO Medication Reconciliation requirements to ensure a complete medication history upon admission, the patients understand
their therapy plan and their therapy, and medication is reviewed between each site of care. Patients should understand their medication prior to discharge,
and the medication records should be available to other practitioners providing care to the patients.

Patients should understand their medication sufficiently to participate in therapy decisions.

Patients should understand the importance of compliance, how to monitor for therapy effectiveness or adverse effects, and the appropriate course of action.

Current and appropriate drug information and other related compendia are available for all members of the institution/practice.

Regular education is provided to other members of the healthcare team in a timely manner.

Therapy updates from the literature or institutional committees, such as the Pharmacy and Therapeutics Committee

Results of institutional decisions, studies, and evaluations.

FDA-related information such as new drug approval, changes in indications, warnings, recalls, or discontinuation of availability.

Pharmacy services should participate in multidisciplinary rounds, committees, and conferences.

Guideline V
Pharmacy Services should contribute to the financial and legal requirements associated with the patient’s therapy.

Rationale
A complete and accurate patient bill is important to ensure reimbursement. Pharmacy systems should be designed to ensure that required billing information is complete and accurate in the patient record. All required records should be complete and meet legal requirements for required information and confidentiality (HIPAA). Pharmacy Services can also contribute to the development of budgets, influence effective cost management, and perform cost/outcome analysis of therapy.

Characteristics

The drug therapy indication is appropriate for the patient diagnosis and is documented during the ordering process.

References are provided for drugs being used outside of indications that have already been approved by payers.

Appropriate billing codes and dosing increments are used as determined by the payer.

Systems are in place to identify and enroll patients into “manufacturer patient assistance programs” and other charitable programs when appropriate.

Pharmacy Services will assist with developing budgets related to the procurement and provision of drug therapy.

All pharmacy and medication records should meet all legal standards including, but not limited to, HIPAA.

Please note: While every attempt has been made to ensure the accuracy of the publications, addresses, phone numbers, and websites, ACCC cannot ensure that this information has not changed. Web addresses, in particular, change frequently. If you find that a web address has changed, try to locate the publication name through an online search engine.

Section 6: Psychosocial Oncology Care

Guideline I
Psychosocial oncology services,also called psychosocial distress management services* are provided to address the psychological, emotional, spiritual, social, and practical aspects that patients and their families have as a consequence of cancer and its treatment.

* Distress management is the term developed by the National Comprehensive Cancer Network in its series of Clinical Practice Guidelines. Patients and families may find Distress Management less threatening and more understandable than psychosocial oncology care so its use is appropriate when developing an individual program.

Rationale
The diagnosis and treatment of cancer cause levels of distress that vary from normal to severe and may interfere with treatment. The continuum of feelings experienced by cancer patients and their families range from normal feelings of vulnerability, sadness, and fears to problems that are disabling, such as depression, anxiety, panic, and feelings of isolation or spiritual crisis. Distress, like pain, should be promptly recognized and managed. Referral to qualified professionals (including clergy for those in spiritual crisis) can help provide an optimal quality of life. Since patients and their families are more likely to understand the term “distress management” than psychosocial oncology care, its use is appropriate and may encourage self-reporting.

Characteristics

Psychosocial care includes, but is not limited to:

Oncology social work services in which

Patients and their families are screened for psychological distress and further evaluated if required for advocacy, education, and case management in solving the concrete everyday needs that may be exacerbated by their cancer diagnosis.

Patients and their families are screened for psychological distress and further evaluated if required for education, counseling, support, and advocacy for their psychosocial problems, including conflict/isolation, treatment decisions, quality-of-life issues and transitions in care, advance directives, domestic violence, coping/communication, and functional changes.

Support groups are offered or referrals are made to a group that meets the patient’s and family’s needs.

Complementary programs are provided or can be referred to.

Patients and their families are evaluated, referred, and managed for psychological/ psychiatric disorders, including adjustment, anxiety, and personality disorders, and substance abuse.

Implementation of standards of care as defined in clinical practice guidelines

Assurance that distressed patients and families are identified and treated promptly and appropriately per NCCN Distress Screening Guidelines

Establishing or approving protocols for rapid screening and evaluation per NCCN Guidelines

Assuring proper qualifications and credentials of the providers.

Guideline IIPsychosocial care of cancer patients and their family is provided by oncology social workers with specialized knowledge and skills in oncology.

RationaleThe complex psychosocial needs of patients with cancer and their families require specialized oncology social work knowledge and skills to achieve optimal care outcomes.

Characteristics

The oncology social worker is an integral part of the multidisciplinary team.

Oncology social workers have master’s degree in social work.

Certification in oncology social work (OSW-C) is recommended and recognized.

Oncology programs provide adequate oncology social work staff to meet the needs of patients and their families.

A plan is in place regarding on-going staff development, including participation in multidisciplinary team conferences, regularly scheduled in-services, and continuing education programs, specific to oncology social work.

Association of Oncology Social Work standards and guidelines for all aspects of patient care, professional practice, research, education, and administrative components should be referenced when developing individual programs.

REFERENCES

Please note: While every attempt has been made to ensure the accuracy of the publications, addresses, phone numbers, and websites, ACCC cannot ensure that this information has not changed. Web addresses, in particular, change frequently. If you find that a web address has changed, try to locate the publication name through an online search engine.

The Association of Oncology Social Work. Standards of Practice in Oncology Social Work, 2001. http://www.aosw.org
Phone: 215.599.6093.

Educating patients and families about pain resources available and helping them to achieve realistic goals that meet their specific needs based on the clinical disease and the impact of the disease on the patient and family members.

Assessing and reassessing pain treatment to include efficacy defined by change in visual analogue score, timeliness, improvement in functional capacity and safety, and customization of therapy defined by establishing treatment goals with the patient and family and readjustments determined by changes in the patient’s disease or through shared decision making with the patient and family.

Methodology should be established to monitor processes and outcomes of pain management. Quality outcomes measurement should include practice patterns and patient outcomes that are goal oriented and easy to collect.

Clinical experts in pain management should be identified and available for consultation.

Patient education and treatment planning include the family or care providers.

Physician and staff education is provided to ensure clinical competency in pain assessment and management.

Staff is encouraged to become involved in local and national advocacy and legislative efforts addressing barriers to pain relief.

REFERENCES

Please note: While every attempt has been made to ensure the accuracy of the publications, addresses, phone numbers, and websites, ACCC cannot ensure that this information has not changed. Web addresses, in particular, change frequently. If you find that a web address has changed, try to locate the publication name through an online search engine.

Section 8: Nutrition Services*

*Revised March 2012

Guideline IA nutrition professional is available to work with patients and their families, especially patients identified at risk for having nutritional problems or special needs.

RationaleNutritional status can be adversely affected by the disease process, including the symptoms and side effects of cancer and its treatment (e.g., chemotherapy, surgery, immunotherapy, and radiation therapy). The nutrition professional works with patients, families and/or caregivers, physicians, and other members of the oncology multidisciplinary team to help maintain optimal nutritional status throughout the continuum of care (prevention, treatment, survivorship, palliative care, and hospice).

Characteristics

The nutrition professional is a registered dietitian and maintains registration through the Commission on Dietetic Registration (CDR). Certification in oncology nutrition as a Certified Specialist in Oncology Nutrition (CSO) through the CDR is recommended.

The nutrition professional has education and experience in the specialized nutritional needs of patients with cancer, side-effect management, and in minimizing the risk of cancer through nutritional counseling and education.

Staffing of nutrition professionals is adequate to meet the needs of cancer patients and their families in a timely manner.

The nutrition professional provides education and guidance to physicians and other members of the oncology team to assure appropriate screening, assessment, and referral of patients.

The nutrition professional participates in oncology multidisciplinary team conferences and the institutional Cancer Committee.

Oncology nutrition standards for all aspects of patient care and professional practice are guided by the Academy of Nutrition and Dietetics* Standards of Practice and Professional Performance for Registered Dietitians (Generalist, Specialty, and Advanced) in Oncology Nutrition Care.

A plan is in place regarding ongoing professional development for the nutrition professional, including regularly scheduled in-service and continuing education programs through national and regional professional organizations (e.g., the Oncology Nutrition Dietetic Practice Group of the Academy of Nutrition and Dietetics) and community-sponsored programs specific to oncology nutrition.

*Effective January 2012, Academy of Nutrition and Dietetics (AND) became the new name for the American Dietetic Association.

Guideline IIThe nutrition professional with the patient, family, and the oncology team manages issues involving the patient’s nutrition and hydration status through appropriate nutrition screening, assessment, and intervention across the care continuum.

RationaleThe nutritional needs of patients are unique to each individual.

Characteristics
As part of the nutrition care process, the nutrition professional:

Develops and implements a screening program to identify and prioritize patients at risk for malnutrition.

Formulates an individualized nutrition care plan based on assessment findings.

Provides anticipatory guidance, identifying common nutritional problems the patient may encounter during the course of his/her disease and treatment.

Assesses the patient’s and/or family’s ability to understand and comply with nutritional education and instruction and modifies interventions appropriately.

Collaborates in the patient’s care with his/her physician(s) and other members of the oncology team.

Evaluates nutrition care outcome indicators.

Guideline IIIThe nutrition professional serves as a resource and provides nutrition and diet information about reducing cancer risk and cancer recurrence risk through educational program materials and services to the community.

RationaleLifestyle interventions that are associated with reduced cancer risk also address chronic disease as a whole, improving the health and knowledge base of the community that the cancer center serves.

Characteristics

The nutrition professional provides dietary and lifestyle guidance associated with reduced cancer risk through the delivery of educational materials, programs, and services to the community.

The nutrition professional works with health professionals and educators to provide evidence-based information about lowering cancer risk, both for primary prevention and to prevent recurrence and secondary cancers in survivors.

Please note: While every attempt has been made to ensure the accuracy of the publications, addresses, phone numbers, and websites, ACCC cannot ensure that this information has not changed. Web addresses, in particular, change frequently. If you find that a web address has changed, try to locate the publication name through an online search engine.

Section 9: Rehabilitation Services

Guideline I
Comprehensive rehabilitation services are available to cancer patients and their families through the entire continuum of care from diagnosis through survivorship.

RationaleCancer is a chronic disease that may require adjustment in the physical, social, financial, and emotional aspects of life in order to maximize independence and quality of life within medical status. Professionals experienced in rehabilitation are best suited to meet these needs of cancer patients.

Qualified volunteer services to provide support and advocacy for cancer patients and their families

Other complementary services, such as music/art therapy, relaxation, massage, and others may be used in conjunction with rehabilitation disciplines.

Each healthcare discipline is available on staff or by consult to facilitate continuity of care for rehabilitation services. All outsourced services should be provided by properly credentialed individuals whose performance is reviewed annually.

Mechanisms exist, when necessary, to review the rehabilitation plan and coordinate communication among the various members of the rehabilitation team.

Rehabilitation services are a part of the organizational structure of the program and follow proper policies and procedures.

Ongoing educational opportunities are available to members of rehabilitation services.

A mechanism is in place to inform patients and family members of the services available.

REFERENCES

Please note: While every attempt has been made to ensure the accuracy of the publications, addresses, phone numbers, and websites, ACCC cannot ensure that this information has not changed. Web addresses, in particular, change frequently. If you find that a web address has changed, try to locate the publication name through an online search engine.

Section 10: Patient Navigation Services

Guideline I
A patient navigation program is available for patients, their families, and caregivers to help "overcome health care system barriers and facilitate timely access to quality medical and psychosocial care from pre-diagnosis through all phases of the cancer experience."*

*From a definition created by C-change, May 20, 2005. Permission granted. "Patient navigation in cancer care refers to individualized assistance offered to patients, families, and caregivers to help overcome health care system barriers and facilitate timely access to quality medical and psychosocial care from pre-diagnosis through all phases of the cancer experience."

Rationale
The diagnosis and treatment of cancer and living with the disease may be confusing, intimidating, and overwhelming for an individual, family member, or caregiver. Cancer programs have a responsibility to assist our patients, their families, and caregivers to navigate the continuum of care through a navigation program developed by the cancer program or via a partnership with a community agency that utilizes patient navigators. Since each cancer program understands its unique patient population and its community, individual programs or health systems can best create a navigator system that suits its needs.

Characteristics

Patient navigation may include but is not limited to oncology social worker(s) and nurses(s) who may:

Act as a coordinator to ensure the patient, their family members, and caregivers move through the complexities of the system in a timely fashion

Provide psychosocial services to patients, families, and caregivers or refer to oncology social worker for psychosocial care

Trained volunteers and non-clinical paid staff may provide some of the navigator activities and functions under defined conditions with professional oversight.

Cancer programs may choose to select, train, and oversee their own volunteers or non-clinical paid staff.

Cancer programs may choose to partner with an organization that employs patient navigators or uses volunteers
a) The cancer program will help determine who will oversee these navigators
b) The cancer program will develop a contract between the navigator(s) and the program that clearly outlines the role it will have with patients and families.
c) The cancer program will develop an orientation and training program that the navigators must attend.
d) The cancer program will provide an ongoing in-service education program for the navigators.

The program should provide adequate space for confidential interviews and counseling.

Navigators should receive training in ethnic, cultural, and religious diversity as well as ethics.

Mechanisms exist, when necessary, to review the plans and coordinate among team members.

Navigators should facilitate communication between patient and providers.

Navigators should educate the oncology staff about the navigator program and how it will be integrated into the oncology program.

REFERENCES

Please note: While every attempt has been made to ensure the accuracy of the publications, addresses, phone numbers, and websites, ACCC cannot ensure that this information has not changed. Web addresses, in particular, change frequently. If you find that a web address has changed, try to locate the publication name through an online search engine.

Section 11: Genetic Risk Assessment, Counseling, and Testing

Guideline I
Genetic risk assessment programs are available, or referral relationship exists, for people at risk for inherited cancers. These programs assess medical and family history and provide genetic counseling tailored to individual or family risk of cancer.

Rationale
Identifying familial cancer patterns can be useful in recommending early detection and prevention strategies for affected individuals.

Characteristics

Genetic risk assessment programs include the following elements:

Identification of the high-risk client through personal medical history, family history (paternal and maternal), pedigree construction, and additional information to confirm cancer diagnoses.

Provision of information about early detection, risk reduction, and preventive strategies that are personally tailored to the client as well as the general public.

Risk assessment involves a genetics team of healthcare professionals including: physicians and nurses trained in genetics, board-certified genetic counselors, psychologists, and other specialists.

Guideline II
Genetic predisposition testing is available for individuals who have undergone thorough risk assessment and counseling by the genetics team and are considered appropriate candidates for testing.

Rationale
Genetic testing, a multi-step process, is fundamentally different from other clinical tests because of its inherent complexities. It is one component of a comprehensive cancer risk assessment plan.

Characteristics

Individuals seeking genetic testing should be considered according to the following criteria:

There is a reasonable likelihood (based on risk assessment) of carrying an altered cancer susceptibility gene.

Genetic counseling by a qualified healthcare professional is a crucial component of genetic testing.

Genetic testing has implications for the entire family, such as disclosure of results, breach of confidentiality, and clarifying each family member’s risk and options for testing.

Testing will, ideally, begin with a family member affected with cancer.

Motivations for testing will be carefully considered.

Informed consent procedures will be strictly enforced and include the potential benefits, risks, and limitations of genetic testing.

Post-test counseling and longitudinal follow-up will be part of the testing process.

REFERENCES

Please note: While every attempt has been made to ensure the accuracy of the publications, addresses, phone numbers, and websites, ACCC cannot ensure that this information has not changed. Web addresses, in particular, change frequently. If you find that a web address has changed, try to locate the publication name through an online search engine.

Section 12: Home Care

Guideline I
A home health agency or referral relationship exists to provide professional services to cancer patients and their families in the home.

Rationale
Cancer is a chronic disease with intermittent, acute episodes resulting in care being delivered in various settings, such as in primary, tertiary, ambulatory, rehabilitation, extended care, and home settings.

Characteristics

A home health agency must be accredited by a national organization such as JCAHO and can be owned by or have a referral relationship with the hospital to provide the following multidisciplinary professional services:

Oncology nursing

Clinical nutrition

Pharmacy

Psychosocial services

Rehabilitation services

Spiritual support

Home health aide and homemaker services are available.

The home health agency has written policies and procedures for care of the cancer patient, which are compatible with those of the referring institution.

A physician-authorized plan of treatment specific to each patient is established.

Guideline II
The home health agency staff is capable of providing appropriate and competent care for cancer patients and their families at any stage of the disease.

RationaleOncology care of the cancer patient requires specialized knowledge. Experienced oncology nurses and oncology social workers should be available to care for or consult on the care of the cancer patient at home. (See Chapter 4, Section 4, Oncology Nursing Services. and Section 6, Psychosocial Oncology Care.)

Characteristics

Access to oncology nurse experts or anoncology clinical nurse specialist, or an established oncology nursing team should be provided within the home health agency.

Oncology nurses in home care should demonstrate competence and expertise in the following areas:

Knowledge of all treatment modalities, side effects of diseases and treatments, stages of disease, and subsequent outcomes

Administration and safe disposal of cytotoxic drugs

Appropriate referral to other professional services and community-based resources

Assessment of and intervention for oncologic emergencies

Assessment and management of pain, nausea, vomiting, malnutrition, fatigue, dehydration, and other side effects of treatment and disease

Skin and wound care

Management of vascular access devices.

Ongoing staff education in the area of cancer services should be provided to oncology staffs in home care.

Access to oncology social work experts or an established oncology social worker should be provided within the home health agency.

Oncology social worker in home care should demonstrate competence and expertise in the following areas: resource development, advocacy, education, psychosocial assessment, and counseling.

REFERENCES

Please note: While every attempt has been made to ensure the accuracy of the publications, addresses, phone numbers, and websites, ACCC cannot ensure that this information has not changed. Web addresses, in particular, change frequently. If you find that a web address has changed, try to locate the publication name through an online search engine.

Section 13: Palliative Care

Guideline I
Appropriate policies and procedures for providing palliative care are available to professional staff to assist patients in achieving maximum comfort and relief of suffering at the end of life.

Rationale
Palliative care is the active intervention to achieve the maximum comfort and function of the total patient. Palliation (relief of symptoms) should always be an important part of patient care. In the advanced cancer patient, it may be the only care when curative care is no longer the goal. Palliative care should attend to the physical, emotional, psychological, social, cultural, and spiritual needs of the patient.

Characteristics

Palliative care is an integral part of the comprehensive spectrum of patient care.

Palliative care is available when curative treatment is no longer considered a goal.

Professional staff is educated about the physical, emotional, spiritual, and psychosocial components of palliative care in relieving suffering and providing comfort at the end of life.

Palliative care is a multidisciplinary effort, involving physicians, nurses, social workers, clergy, and other members of the healthcare team, to maximize comfort and support that respects the patient’s wishes, values, culture, and traditions.

Palliative care requires continuous, effective communication with the patient and his or her family to ensure that goals are mutually set and understood by the multidisciplinary team, the patient, and his or her family.

Professional staff has a responsibility to discuss, with the patient and his or her family, issues such as withholding/withdrawing various therapeutic measures, artificial feeding and hydration, cardiopulmonary resuscitation, and any other measures that may impact the patient’s quality of life.

REFERENCES

Please note: While every attempt has been made to ensure the accuracy of the publications, addresses, phone numbers, and websites, ACCC cannot ensure that this information has not changed. Web addresses, in particular, change frequently. If you find that a web address has changed, try to locate the publication name through an online search engine.

Section 14: Hospice

Guideline I
A hospice program exists to provide professional and volunteer services to patients with cancer in the terminal stage of disease and their families. Bereavement support for families is provided for a minimum of six months.

Rationale
The palliative and supportive services of a hospice program provide physical, psychosocial, and spiritual care for patients with terminal cancer diagnoses and their families.

Characteristics

Multidisciplinary hospice services are available to dying patients and their families and include home-based hospice, inpatient hospice, residential hospice or respite care. Services provided include medical, nursing, psychosocial, spiritual, and bereavement. Services may be provided by hospice program staff, volunteers, or through a written agreement(s) with an individual, institution, or agency.

The hospice program assures continuity of care through assessment of the patient and family needs, development and review of the care plan, and management of care needs until discharge or until death and the bereavement period.

A medical staff or director is responsible for the supervision and quality of hospice services.

Hospice services are provided with sufficient nursing personnel to meet the level of care required by hospice patients.

Respite care is available to family and other caregivers.

The hospice program meets appropriate licensing and accreditation requirements.

Policies and procedures are established for all hospice components including: admission and discharge criteria, bereavement care, and psychosocial, medical and nursing care management.

REFERENCES

Please note: While every attempt has been made to ensure the accuracy of the publications, addresses, phone numbers, and websites, ACCC cannot ensure that this information has not changed. Web addresses, in particular, change frequently. If you find that a web address has changed, try to locate the publication name through an online search engine.

Section 15: Pastoral Care

Guideline I
Pastoral care services are available to meet the needs of all patients and their families with consideration of diversity in religious preferences.

Rationale
Spiritual and psychological issues are confronted by cancer patients and their families, staff members, and the community at-large; therefore, effective pastoral care is an integral part of relating to such issues. Staff respects the personal integrity, spiritual beliefs, and traditions of each individual and assists in creating an environment of acceptance, reflection, and expression of spiritual needs.

Characteristics

Pastoral care is supervised by a qualified professional chaplain with appropriate education (college and accredited theological school) and clinical training (four units of clinical pastoral education are preferred).

Spiritual needs may be identified and referred to a professional chaplain by all members of the oncology team.

Spiritual assessment by a professional chaplain is incorporated into basic patient assessment.

A clearly defined and functional referral system is established and maintained.

Pastoral care involves sacramental, liturgical, and counseling services in keeping with the beliefs of patients and their families.

Spiritual guidance in decision making related to patient care and biomedical ethics is available to patients and their families as well as caregivers.

Ongoing multidisciplinary staff education and support is provided.

Pastoral care recognizes diversities of faith, culture, and race. (A professional chaplain, as defined by the Joint Commission for Accreditation of Pastoral Services (JCAPS) standards, is equipped with the knowledge and sensitivity to deal with the diversity of faith, culture, and racial traditions.)

Pastoral care staff communicates with and supports clergy in the community.

Pastoral care is available to staff members through individual counseling and group sessions.

Bereavement care and services are available to patients and their families.

Please note: While every attempt has been made to ensure the accuracy of the publications, addresses, phone numbers, and websites, ACCC cannot ensure that this information has not changed. Web addresses, in particular, change frequently. If you find that a web address has changed, try to locate the publication name through an online search engine.

The Council on Ministries in Specialized Settings (COMISS) Commission on Accreditation of Pastoral Services (CCAPS). Approved Oct. 2000.http://www.comissnetwork.org.
Phone: 757.388.2850.

Complementary therapies are provided in parallel with the conventional treatment plan and also when curative treatment is no longer considered a goal.

Complementary therapies should be provided by the cancer facility whenever possible. In addition to or as an alternative, the cancer facility may seek collaborative agreements with credible community agencies and individual reputable providers to help patients access appropriate care. When working with outside providers, the facility needs to do due diligence in order to endorse the particular providers.

Professional staff performing complementary services and therapies should be licensed healthcare providers to the extent dictated by individual state licensure requirements.

Traditional practitioners have the responsibility to endorse complementary services that the program determines have medical credibility and should advise their patients against seeking alternative care (used instead of conventional evidence-based therapies) or treatments that may minimize the effectiveness of their current conventional therapies.

Section 17: Survivorship Services

Guideline I
Information and program specific to survivorship issues are available to cancer patients and their families.

Rationale
Survivorship is defined as the experience of living with, through, and beyond cancer for both patients and the people in their lives who are impacted by the diagnosis. It comprises the physical, psychological, emotional, social, spiritual, and economic aspects of life that may be influenced by cancer at any time from diagnosis through treatment and all remaining years of life.

Characteristics

Programs and educational resources for survivors and their families should include but are not limited to the following:

A written cancer treatment summary and follow-up care plan that would include a summary of the cancer treatment, recommended follow-up for cancer surveillance, late and long-term effects of their disease and its treatment(s), symptom management, as well as psychosocial, spiritual, and financial concerns. Access to information about cancer prevention, early detection, genetics, disease treatment, symptom management and psychosocial, spiritual, financial concerns through written materials and/or referrals via the Internet, other experts, or support organizations

Information about local, regional, and national resources on survivorship and survivorship research via written materials and/or referrals through the Internet, other experts, or support organizations for any aspect of their cancer, cancer care, research, advocacy, and survivorship

Access to support groups either on-site or by referrals to local or web-based support groups and other support mechanisms, such as telephone connection programs linking survivors together

Information about specific survivorship issues, such as employment rights, insurance coverage, late and long-term effects of disease and treatment, advance directives, living will and durable power of attorney, estate planning, options for recurrent disease management, and end-of-life care planning

Programmatic opportunities to participate with the care team to develop community outreach education and support programs for quality cancer care in the community and to educate professional staff about the cancer experience.

Resources are allocated to provide a robust survivorship program.

National standards for survivorship will be incorporated into program planning, implementation, and evaluation.

Section 18: Patient Advocacy and Financial Services

Guideline I
Patient advocate is available to assess and explain insurance benefits and coverage eligibility to patients and their families.

Rationale
The diagnosis and treatment of cancer can cause levels of distress that vary from normal to severe and may interfere with the ability of patients and families to process complex information related to insurance benefits and coverage.

Characteristics

Depending on the cancer program and the patient population, patient advocacy and financial services may be performed by office staff, nurses, social workers, case managers, and/or professional or lay patient navigators. Ongoing training is important to maintain a thorough knowledge base.

The patient advocate will develop a system or tools to manage and track all interactions with third-party payer(s), including Medicare and Medicaid, as well as patient assistance, drug replacement and grant sites.

Patient advocate performs insurance verification with all third party payers.

Patient advocate ensures all demographic, insurance, and eligibility information is obtained and current. Patient advocate will develop a system to track and update insurance information, including policies related to medical necessity, prior or pre-authorizations, and appeals.

Patient advocate obtains initial and subsequent pre-authorizations. Patient advocate will track the number of treatments permitted before pre-authorizations must be renewed and ensure that pre-authorizations do not run out or expire.

Guideline II
Patient advocate is available to assess and explain treatment costs to patients and their families.

Rationale
The diagnosis and treatment of cancer can cause levels of distress that vary from normal to severe and may interfere with the ability of patients and families to process complex financial information related to the cost of treatment.

Characteristics

Depending on the cancer program and the patient population, patient advocacy and financial services may be performed by office staff, nurses, social workers, case managers, and/or professional or lay patient navigators. Ongoing training is important to maintain a thorough knowledge base.

Patient advocate meets with the patient and family prior to the start of treatment to discuss the costs of the prescribed treatment regimen.

At this face-to-face meeting, the patient advocate identifies all out-of-pocket costs for the patient. These out-of-pocket expenses can include: co-insurance, deductibles, and co-pay amounts.

If necessary, the patient advocate will work with the patient and family to outline a payment plan for the costs of treatment. This plan should be a written agreement that is signed by the patient.

Patient advocate will work with patients and families to identify other costs, such as expenses related to transportation, childcare, and lodging, if patient must travel to receive treatment.

If necessary, the patient advocate will work with the patient and family to identify patient assistance programs that can help with non-treatment-related costs. If patients are eligible, the patient advocate will help patients and families apply to these program(s).

Guideline III
Patient advocate is available to screen patients and, when necessary, to help patients and families apply to appropriate federal- or state-run program(s).

Rationale
The diagnosis and treatment of cancer can place an undue financial burden on patients and their families. Lack of insurance, high co-pays, and high deductibles may result in patients choosing not to seek treatment, to stop treatment, or to delay treatment.

Characteristics

Depending on the cancer program and the patient population, patient advocate and financial services may be performed by office staff, nurses, social workers, case managers, and/or professional or lay patient navigators. Ongoing training is important to maintain a thorough knowledge base.

Patient advocate will gather information about federal and state programs, such as Medicaid, including eligibility requirements and information about the application process.

If patients are eligible, the patient advocate will help patients and families apply to federal and/or state programs.

Guideline IV
Patient advocate is available to screen patients and, when necessary, to help patients and families apply to appropriate patient assistance program(s).

Rationale
The diagnosis and treatment of cancer can place an undue financial burden on patients and their families. Lack of insurance, high co-pays, and high deductibles may result in patients choosing not to seek treatment, to stop treatment, or to delay treatment.

Characteristics

Depending on the cancer program and the patient population, patient advocacy and financial services may be performed by office staff, nurses, social workers, case managers, and/or professional or lay patient navigators. Ongoing training is important to maintain a thorough knowledge base.

For uninsured patients, patient advocate will help patients and families identify appropriate patient assistance programs to help pay for treatment-related costs. The patient advocate will then help patients and families fill out applications and serve as a liaison between the patient, the cancer program, and the patient assistance program(s).

For under-insured patients and patients who cannot afford the cost of treatment, patient advocate will help patients and families identify appropriate patient assistance programs, usually referred to as "co-pay programs." The patient advocate will then help patients and families fill out applications and serve as a liaison between the patient, the cancer program, and the patient assistance program(s).

Patient advocate will develop a system or tools to manage and track all interactions with patient assistance.

Guideline V
Patient advocate is available to screen patients for financial needs not directly related to oncology diagnosis and treatment and, when necessary, to help patients and families apply to appropriate patient assistance program(s) and/ or make appropriate support referrals.

Rationale
The diagnosis and treatment of cancer can place an undue financial burden on patients and their families. Many patients and families may have finance-related needs prior to a cancer diagnosis that are either increased or compounded by a cancer diagnosis. These finance-related needs may result in patients choosing not to seek treatment, to stop treatment, or to delay treatment. They may also increase the stress levels of the patient and family which could affect outcomes.

Characteristics

Depending on the cancer program and the patient population, patient advocacy and financial services may be performed by office staff, nurses, social workers, case managers, and/or professional or lay patient navigators. Ongoing training is important to maintain a thorough knowledge base.

Patient advocate will gather information about local, state, national and private support programs available to their oncology population, including services, contact information, any eligibility requirements, information about the application process and any other pertinent information.

Patient advocate will help patients and families identify appropriate support and patient assistance programs. to help pay for treatment-related costs. The patient advocate will then help patients and families fill out applications and serve as a liaison between the patient, the cancer program, and the patient assistance program(s) as appropriate.

Patient advocate will develop a system or tools to manage and track all interactions with patient assistance.

REFERENCES

Please note: While every attempt has been made to ensure the accuracy of the publications, addresses, phone numbers, and websites, ACCC cannot ensure that this information has not changed. Web addresses, in particular, change frequently. If you find that a web address has changed, try to locate the publication name through an online search engine.

Additional resources may be obtained from patient advocacy organizations, including
The National Patient Advocate Foundation at www.patientadvocate.org.
Phone: 800.532.5274.
American Cancer Society at www.cancer.org.
Phone: 800.ACS.2345.